- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,252.91 / $1,252.91 / $1,252.91
| Facility | | $1,252.91 | $1,252.91 | $1,252.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $910.95 / $1,252.91 / $1,252.91
| Professional | | $910.95 | $1,252.91 | $1,252.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $810.32 / $1,492.56 / $3,707.97
| Professional | | $810.32 | $1,492.56 | $3,707.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,271.33 / $1,494.29 / $2,185.02
| Professional | | $1,271.33 | $1,494.29 | $2,185.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,372.38 / $1,683.89 / $3,989.60
| Professional | | $1,372.38 | $1,683.89 | $3,989.60 |